Guideline 74: The management of harmful drinking and alcohol dependence in primary care

The management of harmful drinking and alcohol dependence in primary care
Section 5: Referral and follow up

5.1 Who to refer, and to whom

Specialist treatments for alcohol problems are effective. A health technology assessment from NHS Quality Improvement Scotland concluded that specialist services are effective for relapse prevention if offering behavioural self control training, motivational enhancement therapy, family therapy/community reinforcement approach and/or coping/communication skills training (see Annex 8).¹¹⁵ Evidence level 1++

General Practitioners are able to manage more patients with alcohol related problems if they perceive that they are working in a supportive environment which includes access to help with difficult patients.¹¹⁶ Evidence level 4

Research aiming to predict which patients will do better with which type of specialist treatments has given few leads. The GP’s decision where to refer a patient should be guided in large part by the patient’s choice. Some predictors however, have emerged: patients who are angry at the initial assessment appear to do better, in the short term, if given motivational interviewing.^{117,
118} Patients with psychiatric disorders (‘dual diagnosis’) tend to do better if referred to specialist psychological or psychiatric services than to 12-step Alcoholics Anonymous (AA) groups.¹¹⁹ Patients referred to specialist care, who live or work in environments where there is a lot of drinking and little support for abstinence, may do better in a service which offers consultations which emphasise the 12-step AA approach, rather than specialised psychological therapy. Evidence level 1+,2++

One underpowered study found no advantage to specialist treatment over general practice management in the UK.¹²⁰ Two North American studies have shown that milder alcohol dependence can sometimes be successfully managed without specialist care.^{121,
122} However, brief primary care intervention has usually excluded alcohol dependent patients who should, in general, be referred for specialist care. Evidence level 1-,1+

Access to relapse prevention treatments of established efficacy should be facilitated for alcohol dependent patients.

5.1.1 PATIENTS WITH ALCOHOL RELATED PHYSICAL DISORDER

American studies have shown that for patients with alcohol related physical disorders, integrated medical care and addiction treatment gives a better outcome than when the two services are separate.^{122,
123} If this is extrapolated to the NHS, it suggests that these are patients for whom particularly good links between the alcohol agency and medical care should be nurtured or where the treatment of the alcohol problem should be based as much as possible in primary care. Evidence level 1+,4

When the patient has an alcohol related physical disorder, the alcohol treatment agency should have close links with the medical and primary care team.

5.1.2 STEPPED CARE

Stepped care¹²⁴ (in a tiered treatment service^{2,
125}) occurs when treatment is chosen where possible to match the patients’ needs and wishes and cause least disruption to their family and their work. More intensive treatment is only required if the outcome is unsatisfactory. Evidence level 4

The principles of stepped care should be followed for patients with alcohol problems and dependence.

5.2 Waiting time to referral

Two case control studies and one cohort study found that increased waiting times made attendance at specialist clinics less likely.^{126,
127, 128} None found a link between delay in referral or waiting time for assessment with ultimate outcome of treatment. Evidence level 2+

5.3 Monitoring

Low intensity monitoring over the course of one to three years has been shown to reduce the severity of relapses.^{129,
130} This may be done by telephone or a brief appointment. In these studies, benefit may have been partly due to earlier rereferral to specialist services. Evidence level 1+

Primary care teams should maintain contact over the long term with patients previously treated by specialist services for alcohol dependence.

5.4 Effectiveness of lay services

5.4.1 ALCOHOLICS ANONYMOUS

The health technology assessment from NHS Quality Improvement Scotland supports the appropriate use of AA.¹¹⁵ Evidence level 2+

Alcoholics Anonymous believes that alcohol dependence is a chronic and progressive illness without cure, for which total abstinence is the only solution. Alcoholics Anonymous is widely available and entirely self-funding, but there is limited formal evidence of efficacy from randomised studies. It is a network of support including advice for individuals in crisis. Their members are willing to help primary care teams link patients with AA. Evidence level 2+

Alcohol dependent patients should be encouraged to attend Alcoholics Anonymous.

5.4.2 OTHER LAY AND NON-STATUTORY SERVICES

Motivational interviewing and coping skills training for relapse prevention have been shown to be effective when delivered by psychologists.¹³¹ Counselling by lay and non-statutory agencies is available in most of Scotland (eg by Councils on Alcohol) but has not been evaluated in controlled studies.¹³² These agencies welcome referrals from NHS primary care. The evidence for efficacy of client-centred counselling for alcohol dependence is conflicting. Less defined counselling and education appear to be ineffective. Day care/drop-in centres are available in certain areas. Evidence level 2+

If patients are referred to a lay service, agencies where lay counsellors use motivational interviewing and coping skills training should be utilised.

5.5 Effectiveness of medications to prevent relapse

The health technology assessment by NHS Quality Improvement Scotland included meta-analyses of the efficacy and cost effectiveness of medications for relapse prevention and found evidence of efficacy for disulfiram (supervised) and acamprosate.¹¹⁵ This was also the conclusion of a health technology assessment by the Swedish Council on Technology Assessment in Health Care¹⁰⁶ and a literature review for the Aberdeen Health Economics Research Unit.³² Evidence level 1++,1+

Other meta-analyses support these findings^{133,
134} as does the joint guideline of the US Agency for Healthcare Research and Quality/American Society of Addiction Medicine (2002). Acamprosate is believed to act by modulating disturbance in the gamma-aminobutyric acid /glutamate system associated with alcohol dependence, reducing the risk of relapse during the postwithdrawal period. It is a safe drug with few unwanted side effects, and is not liable to misuse. Its value is in the first months after detoxification. Acamprosate is not effective in all patients so its efficacy should be assessed at regular appointments, and the drug withdrawn if there has not been a major reduction in drinking. Where it appears to be effective, good practice suggests prescribing for 6-12 months. The studies were conducted in specialist centres where psychosocial treatment was offered. It is an assumption that, as long as there is a system of monitoring compliance and efficacy, these data are applicable to primary care. Evidence level 1++,1+

Acamprosate is recommended in newly detoxified dependent patients as an adjunct to psychosocial interventions.

Acamprosate will usually be initiated by a specialist service within a few days of successful detoxification. If a specialist service is not available, the GP should offer acamprosate, monitor its efficacy and provide links to local support organisations.

Disulfiram’s function is to deter the patient from resuming drinking. If taken regularly there is an unpleasant reaction when alcohol is consumed. It has unwanted effects in some patients, and carries special warnings. The health technology assessment by NHS Quality Improvement Scotland found some support for the use of supervised disulfiram and none for its non-supervised use. ¹¹⁵ If used, it should be offered for six months in the first instance, with regular review. Supervision is agreed by the patient to increase the likelihood that the medication is taken even at times of ambivalence. Evidence level 2+

Supervised oral disulfiram may be used to prevent relapse but patients must be informed that this is a treatment requiring complete abstinence and be clear about the dangers of taking alcohol with it.

Disulfiram supervision may be undertaken by the spouse, healthcare or support worker, or the workplace representative if appropriate.

Naltrexone, although supported by the above reports, and used by specialists in Scotland, is not licensed in the UK for the treatment of alcohol dependence.

5.6 Treating alcohol dependence and anxiety or depression

In patients with an alcohol problem, there is good evidence that most anxiety and depression resolves with standard treatment for alcohol dependence.^{133,
135, 136,
137, 138} Evidence level 1+

For patients with panic disorder and social phobia, there is no consistent evidence of extra benefit of cognitive behavioural therapy beyond the simultaneous treatment for the alcohol problem.^{139,
140} Evidence level 1+

In detoxified patients with definite depressive illness, antidepressants improve depressive symptoms and in some studies drinking outcomes.^{133,
135,
136,
137,
138} The strongest effect is with fluoxetine, although this treatment seems to reduce the beneficial effect of cognitive behavioural therapy in the type of patients characterised by early onset and prominent social problems.¹⁴¹ Therefore caution should be exercised in prescribing selective serotonin reuptake inhibitors (SSRIs) to patients characterised by early onset of alcohol problems and antisocial behaviour. Evidence level 1+

There is insufficient evidence that antidepressants improve drinking outcomes in non-depressed patients.

Patients with an alcohol problem and anxiety or depression should be treated for the alcohol problem first.

If depressive symptoms persist for more than two weeks following treatment for alcohol dependence, consideration should be given to using an SSRI or referring for counselling or specialist psychological treatment along with the relapse prevention treatment.

If severe anxiety symptoms persist for more than two weeks in abstinent patients, consideration should be given to using an SSRI, or referring for specialist psychological treatment along with the relapse prevention treatment.

5.7 Treating alcohol dependence when other psychiatric illness is present

Patients with comorbid schizophrenia/schizoaffective disorder and substance misuse benefit from motivational interviewing, cognitive behavioural therapy and family interventions aimed at decreasing their dependence.^{143,
144, 145,
146} These patients are best treated by specialist services. Evidence level 1+,2+,4

Disulfiram may be used with caution in these patients bearing in mind drug interactions.¹⁴⁷ Evidence level 4

Patients with psychotic disorder and alcohol dependence should be encouraged to address their alcohol use and may benefit from motivational, cognitive behavioural, family and non-confrontational approaches.

Patients with psychoses should be referred for psychiatric advice.

5.8 Effectiveness of alternative therapies

Information on outcomes following use of alternative therapies was found only for acupuncture and transcendental meditation. RCTs and systematic reviews have not demonstrated an effect for acupuncture in the treatment of alcohol dependence.^{148,
149, 150} Evidence level 1+,1-,4

A review of transcendental meditation¹⁵¹ (plus the accompanying erratum¹⁵²) reports that this may be useful as an adjunctive treatment for people with an alcohol or drug dependence. The studies included in this review were heterogeneous and patient selection criteria were not reported. Evidence level 4

There is insufficient evidence to make any recommendations about the use of acupuncture, transcendental meditation or other alternative therapies in treating patients with an alcohol problem.